Provider Demographics
NPI:1780778522
Name:LOOMIS, MARIO G (MD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:G
Last Name:LOOMIS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:225 DOLSON AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-6569
Mailing Address - Country:US
Mailing Address - Phone:845-342-6884
Mailing Address - Fax:845-342-4989
Practice Address - Street 1:225 DOLSON AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-6569
Practice Address - Country:US
Practice Address - Phone:845-342-6884
Practice Address - Fax:845-342-4989
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY198000208200000X
PAMD046328L208200000X
NJ69053208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01553864Medicaid
NY02K271Medicare ID - Type Unspecified
NYF24424Medicare UPIN